4/3/2016
Stuttering in preschoolers:
Multifactorial perspective on its
nature, assessment and treatment
Victoria Tumanova, Ph.D., CF-SLP
Assistant professor, Department of Communication Sciences and Disorders,
Syracuse University
vtumanov@syr.edu
Iowa Conference on Communication Disorders
April 8, 2016
Overview of the talk
• 1st hour
• Nature of developmental stuttering
• Normal disfluency and onset of stuttering in preschoolers
• Spontaneous recovery and its predictors
• 2nd hour
• Constitutional, developmental, environmental and learning factors in
stuttering development
• 3rd hour
• Assessment of stuttering following the multifactorial perspective
• 4th hour
• Treatment approaches for preschool-age children
What is stuttering?
• It is an observable behavior (E)
• Disfluency and Stuttering reflect a disruption in the
smooth transitioning between sounds, syllables , and
words.
• It is a disorder of communication
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What are STUTTERING behaviors?
• BETWEEN-WORD disfluencies
• Interjections
• Revisions
• Phrase repetitions
• WITHIN-WORD disfluencies
Within-word disfluencies
(1) Sound/syllable repetitions
(2) Single-syllable whole word repetitions
(3) Disrhythmic phonation
sound prolongations
broken words
blocks (silent prolongations)
STUTTERING IS A FORM OF SPEECH
DISFLUENCY CHARACTERIZED BY A
RELATIVELY HIGH PROPORTION OF
WITHIN-WORD SPEECH DISFLUENCIES
AND ASSOCIATED BEHAVIORS
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Core behaviors of stuttering
• Basic speech behaviors (=within-word disfluencies)
• Repetitions
• Prolongations
• Silent blocks
• They are involuntary
• They are out of the PWS’s control
• Loss of control
• Helplessness
• Characterizes stuttering as opposed to normally disfluent speech
Secondary Behaviors
• Reactions to core behaviors
• Attempt to end or avoid stuttering
• Are learned patterns
• Escape and avoidance
Normal Disfluency and the
Development of Stuttering
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ONSET OF STUTTERING: THE FACTS
• Onset of stuttering typically between 2-4 years of
age
• Probability of stuttering onset decreases with age
• Lifetime incidence (in USA and Western Europe)
approximately 4-5% of the population
• Incidence is an index of how many people have stuttered
at some time in their lives
• Prevalence ranges from 0.5% to 1%
• Prevalence indicates how wide-spread the disorder is
(how many people currently stutter)
• Higher prevalence in preschool-age children
• Lower prevalence in older children and adults
Yairi and Ambrose 2005
• “Early childhood stuttering” book
• Gathered longitudinal data on 146 CWS and 59 CWNS
• Onset
• Sudden 40%
• Intermediate (over 1-2 weeks) 30%
• Gradual (3 or more weeks) 27%
• First disfluencies
• Only 35% of parents described their child’s disfluencies as
easy repetitions
• More iterations per instance of repetition
• Rapid rate of iterations
• Disfluency clusters
Johnson et al., 1959. The Onset of Stuttering
Disfluency types (at onset) of children thought to be
normally disfluent versus children thought to be stuttering
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Tumanova et al. 2014 study
• Parental concern and frequency of disfluency for preschool-age
children
• When do parents become concerned about their child’s fluency?
• 399 children 3-5:11 y/o and their parents participated
• Overall frequency of disfluencies in CWS and CWNS
• How disfluent are preschool-age children?
• 472 children 3-5:11 y/o participated
Tumanova, V., Conture, E. G., Lambert, E. W., & Walden, T. A. (2014). Speech disfluencies of
preschool-age children who do and do not stutter. Journal of communication disorders, 49, 25-41.
Parental Concern about Stuttering
• 399 children 3-5:11 y/o participated
• Parents of 221 children were concerned
• 164 boys, 57 girls, mean age = 49 months
• average of 8.53% stuttered disfluencies
• average of 3.51% normal/other disfluencies
• Parents of 178 children were NOT concerned
• 93 boys, 85 girls, mean age = 50 months
• average of 1.44% stuttered disfluencies
• average of 2.87% normal/other disfluencies
Tumanova, V., Conture, E. G., Lambert, E. W., & Walden, T. A. (2014). Speech disfluencies of
preschool-age children who do and do not stutter. Journal of communication disorders, 49, 25-41.
Stuttered Disfluencies per 100 words
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Normal/Other Disfluencies per 100 words
Criteria for Stuttering Diagnosis
• We begin to suspect that a child is either stuttering
or at risk for developing a stuttering problem if (s)he
meets BOTH of the following criteria
• Produces THREE or more WITHIN-WORD speech
disfluencies per 100 words of conversational speech
(i.e., sound/syllable repetitions and/or sound
prolongations)
• Parents and/or other people in the child’s
environment express concern that the child stutters.
Stuttering as a disorder: Etiology
(implications for treatment)
• So FAR…
• Stuttering as a behavior
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Overview
Nature interacting with nurture (from Conture,
2001):
If a disorder thought
to be the result of a
combination
of genetic and environ
mental influences, its
etiology can be
referred to as
multifactorial
Example of an
Interaction between
environment (salt) and
person (finger) making
a weakness or difficulty
more pronounced
Constitutional Factors: Genes
• Stuttering often runs in families
• 30 to 60% of PWS have family histories of stuttering
• Research is underway to identify genes associated with stuttering
• Single gene for transient stuttering; two or more genes for chronic stuttering
• Twin studies, adoption studies provide evidence that environmental
factors are also important
• Twin studies show that whether stuttering occurs is 2/3 genetics and 1/3
environment
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Clinical Implications
• Parents should be told that stuttering is often
inherited, not a result of bad parenting
• SLPs can’t change a child’s genes but they can
help modify this child’s environment
Constitutional Factors: Brain Structure and Function
• PWS have less dense white matter tracts in
the area of left operculum (tracts that are
thought to connect sensory, planning and
motor areas of the brain) (Sommer et al.,
2002)
• White matter neuroanatomical differences
have been reported in CWS as well (Chang
et al., 2015)
• Brain areas used for sensory integration are
not efficiently connected to motor planning
and motor execution areas
www.humanconnectomeproject.org
Constitutional Factors: Brain Structure and Function
• Meta-analysis by Brown et al., 2005
• Overactivation in right hemisphere areas that are
homologous to left hemisphere areas active for
speech production
• Overactivation in left hemisphere areas related to
motor control of speech
• Deactivation of left auditory cortex during stuttering
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Sensory and Sensory-Motor Factors
• PWS are slower in initiating a movement
• PWS are more variable
• Slower reaction times
• Slower on nonspeech sequencing
• Slower at tapping at a comfortable rate, but faster and more variable at a fast
rate
• PWS show lower accuracy when performing auditory tasks
• Poorer at auditory-motor tracking
• Weaker-than-normal vocal adjustments to perturbations during sustained
vocalization (Loucks, Chon & Han, 2012)
• Masking and other changes in auditory feedback decrease stuttering
Clinical Implications
• Evidence that treatment changes neurological function
• May suggest that treatments restore effective sensorymotor control of speech
• Because PWS process more slowly, slower speech may
facilitate fluency
• Because of sensory processing deficits, masking, DAF,
attention to kinesthetic feedback may be helpful in
treatment
Constitutional Factors: Emotion and Temperament
• Emotion may increase stuttering, and stuttering may increase
emotion
• Important findings
• PWS are not more anxious than PWNS, but more anxiety produces more stuttering
• Autonomic arousal associated with stuttering
• PWS may have more inhibited temperaments; may be more emotionally
conditionable
• Emotional processes:
• CWS less adaptable to novelty than CWNS
• CWS more emotionally reactive, less emotionally and attentionally
regulated
• Emotions interacting with speech-language planning and
production:
• CWS as apt to stutter during/after positive as negative arousal
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Emotional Development in CWS
• Less adaptability to novelty, change and differences (Anderson,
Pellowski, Conture & Kelly, 2003),
• Lower inhibitory control and attention shifting as well as significantly
greater anger/frustration, approach and motor activation (Eggers, De
Nil, & Van den Bergh, 2010);
• Greater emotional reactivity and lesser emotion regulation (Karrass,
Walden, Conture, Graham, Arnold, Hartfield, et al., 2006),
• More reactivity to environmental stimuli (Wakaba, 1998).
Behavioral inhibition
• Behavioral inhibition refers to a pattern of behavior involving
withdrawal, avoidance, and fear of the unfamiliar.
• CWS are more apt to exhibit BI. There were significantly more CWS in
the high BI group and fewer CWS in low BI group compared to CWNS.
• More behaviorally inhibited CWS, when compared to less behaviorally
inhibited CWS, exhibited more stuttering.
Choi, Conture, Walden, Lambert, & Tumanova (2013). Behavioral
inhibition and childhood stuttering. Journal of Fluency Disorders.
Developmental Factors:
Speech and Language
• Stuttering seems to have its most frequent onset when
the child is mastering more complex language
• Rapid speech and language development may stress
“weak” areas, resulting in stuttering
• We know already that stuttering as a behavior occurs in
longer more complex utterances (=complex language)
• Do Children who Stutter show weaker linguistic skills
and knowledge than their normally-fluent peers?
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Language Development
• Ntourou, Conture, & Lipsey (2011). Meta-analysis of language
contributions to childhood stuttering. American Journal of SpeechLanguage Pathology, 20, 163-179.
• CWS scored significantly lower than CWNS on global normreferenced measures of language development, receptive and
expressive vocabulary, and mean length of utterance (MLU).
Language Development
32
Co-occurring Disorders
• No group differences on articulation test, GFTA, (Clark et al, 2014)
• Preschool-age children (3-6 y/o)
• Stuttering frequently coincides with articulation and/or phonological
disorder (Blood, Ridenour, Qualls & Hammer, 2003)
• About 30% of CWS exhibit mild-severe phonological delays/disorders
• School-age children
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Linguistic Dissociations
• Children who stutter (36%) exhibit significantly more
dissociations or asynchrony within and between
subcomponents of their linguistic formulation processes
than children who do not stutter (18%)
• Dissociation = [a] performance of two subcomponents
fall into 5% of the population + [b] the two
subcomponents must be separated by at least one
standard deviation.
• Possible explanation: Poor “goodness-of-fit” among
(sub)components of linguistic processing system. This
incongruence between components of speech-language
system places strain on speech-language system, resulting
in less fluent speech as more time and energy is devoted
to linguistic formulation processes.
Take-home message
• Even when both CWS and
CWNS are within normal
limits
• CWS syntactic, semantic and
phonological processes slower
than CWNS
• CWS exhibit more
“unevenness” in the
development of language,
vocabulary and articulatory
skills than CWNS
Speech-Language
Production
Semantics
Anderson, J. D., Pellowski, M. W., & Conture, E. G. (2005).
Childhood stuttering and dissociations across linguistic
domains. Journal of Fluency Disorders, 30(3), 219-253.
Phonology
Syntax
Developmental Factors: Cognitive Development
• Intensive cognitive development may compete with fluency
• The “ups” and “downs” in a child’s fluency may reflect spurts of
cognitive development
• After age 3, children may be self-conscious enough to have negative
emotions about stuttering
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The Young Child's Awareness of StutteringLike Disfluency
Ezrati-Vinacour, Platzky, & Yairi (2001)
• Normally fluent preschool and first-grade children watched
videos of two puppets speaking fluently and disfluently
• Which one speaks like you?
• Whose speech do you like better?
Results
• It was found that from age 3, children show evidence of
awareness of disfluency, but most children reached full
awareness at age 5.
• Negative evaluation of disfluent speech is observed
from age 4.
Awareness of Stuttering in preschoolers
• Clark, Conture, Frankel, and Walden (2012). Communicative and
psychological dimensions of the KiddyCAT. Journal of
Communication Disorders
• Preschool-age (3-5:11) CWS had more negative attitudes
towards their own speech than CWNS regardless of age or
gender. Additionally, analysis indicated that one dimension—
speech difficulty—appears to underlie the KiddyCAT items.
Developmental Factors: Social and Emotional
Development
• Emotional arousal increases stuttering and normal
disfluency
• Emotional stress during childhood may trigger or
worsen stuttering
• Some children who stutter—because of a sensitive
temperament—may be more vulnerable to normal
stresses of childhood
• Individuals who stutter appear to be normal in terms of
psychosocial traits
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Developmental Factors: Summary
Speech and Language Processes:
• Even when both CWS and CWNS are within normal limits…
• CWS’s syntactic, semantic and phonological processes are slower than
those of CWNS
• CWS exhibit more “unevenness” in the development of language,
vocabulary and articulatory skills than CWNS
Emotional processes:
• CWS are less distractible, less adaptable to novelty than CWNS
• CWS are more emotionally reactive, less able to regulate their emotion
and attention
Interaction between Emotional and Speech-language processes:
• CWS are apt to stutter during/after positive as well as negative arousal
CWS speech planning and production systems are less well
developed, probably more vulnerable to interference, particularly
emotional/cognitive interference. Also, emotional reactivity may
not be well regulated in CWS.
Environmental factors may interact with
developmental factors to trigger or worsen
stuttering
HELP WANTED
Speech and Language Environment
• Research unclear: Do families of kids who stutter have stressful speech and
language models?
• Speculation about some variables causing stress for vulnerable children:
Possible Speech and Language Stresses
Stressful Adult Speech Models
Rapid speech rate
Complex syntax
Polysyllabic vocabulary
Use of two languages in home
Stressful Speaking Situations for Children
Competition for speaking
Hurried when speaking
Frequent interruptions
Frequent questions
Demand for display speech
Excited when speaking
Loss of listener attention
Many things to say
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Clinical Implications
• Children who stutter may be helped by making
communication easier.
• More one-on-one time when parent can listen
• Slower speech rate
• Language complexity not too far above child’s
level
Environmental factors: Life Events
Stressful life events may precipitate or worsen
stuttering in some children
Stressful Life Events That May Increase a Child’s Disfluency
The child’s family moves to a new house, a new neighborhood or a new city.
The child’s parents separate or divorce.
A family member dies.
A family member is hospitalized.
The child is hospitalized.
A parent loses his or her job.
An additional person comes to live in the house.
One or both parents go away frequently or for a long period of time.
Holidays or visits occur which cause a change in routine, excitement, or anxiety.
A discipline problem involving the child.
The Facts about Stuttering Imply the Following
• Stuttering is an inherited disorder
• It first appears when children are learning the complex coordination of
spoken language
• It emerges in those children whose speech production system is
vulnerable to disruption by competing demands of language, cognition,
and emotion
• After it emerges, it becomes persistent in some children – perhaps those
whose stuttering arouses substantial negative emotion which leads to a
variety of learned behaviors
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LEARNING FACTORS
• Learning is a process leading to changes in a
person/animal as a result of their experiences
• Learning does NOT have to be
• Conscious
• “Correct”, “good for you” or adaptive
• Any overt or behaviorally apparent act
• Types of learning
• Classical conditioning (Ivan Pavlov)
• Operant conditioning (B.F. Skinner)
• Avoidance conditioning
Assessment: Multifactorial
perspective
Stuttering as a Multifactorial, Dynamic
Disorder
• Anne Smith and her colleagues (e.g., Smith & Kelly,
1997) suggest there is no one cause of stuttering, but an
array of factors contributing to it
• The problem is to find the relevant factors and discover
how they interact
• They see stuttering as “dynamic” because behaviors
(repetitions, prolongations, blocks) are only surface
features of an ever-changing process
• Examples of the underlying factors are linguistic load,
speech motor instability, emotional stress, etc.
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Multifactorial Perspective
Smith & Kelly, 1997
Subgroups
• “stuttering recipe”
• for each individual, the
factors may be different and
in different amounts…
• while there is evidence that
subgroups exist among CWS,
not every person is a
“subgroup”
Healey, Scott Trautman, and Susca, (2004). Clinical applications of a multidimensional
approach for the assessment and treatment of stuttering. CICSD, 31, 40-48
Questions for Preschool-age Child Diagnosis
• Is the child stuttering or at risk for stuttering?
• Will the child spontaneously recover/ “outgrow” stuttering?
• How high is the need for and desirability of therapy?
• What should be the initial focus of therapy?
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Assessment:
Caregiver Interview
Interview the parents
• When was the problem first noticed? How old was the child?
• Who noticed the problem? What did he/she do?
• What was the speech like? How has it changed since?
• Do you see consistent amount of disfluency or does it vary
from day to day?
• Do you have a family history of stuttering?
• What do you and others do when the child stutters? Why do
you do it? Does it help?
Caregiver Interview
• Case history
•
•
•
•
•
Gender
Age of onset
Time since onset
Family history of stuttering
Caregiver concern
• Child temperament
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Gender
• 2:1 male-to-female ratio among very young children
(3 yrs) close to the onset of stuttering (Yairi & Ambrose,
2013; Mansson, 2000 and others)
• However, girls recover more frequently so that by the
time children are of school age, the ratio becomes 3
boys to 1 girl who stutters and continues at a 3:1 ratio
• More boys than girls develop chronic stuttering
problems (3:1)
Age of Onset
• Onset of stuttering typically between 2-4 years of age
• Probability of stuttering onset decreases with age
• Age of onset is not currently a prognostic indicator
• Yairi & Ambrose (2005) reported a large overlap in the age of onset
between persistent and recovered CWS.
• Some longitudinal findings show that recovered CWS start stuttering
5 to 8 months earlier than persistent (Watkins & Yairi, 1997)
Time Since Onset of Stuttering
• Research data shows that a large percentage of CWS recover without
treatment
• Estimates of unassisted recovery or remission range from 32%-80%
• Best estimate is 75%
• Probability of recovery highest from 6-12 months post onset
• Majority of children recover within 12-24 months post onset
Yairi and Ambrose 2005 book
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Patterns of Recovery
• Period of recovery marked by steady decrease in sound/syllable and
word repetitions and prolonged sounds over time, beginning shortly
after onset
• Subgroup of children presenting with “severe” stuttering at onset,
with frequency of behaviors peaking at 2-3 months post onset and
full recovery seen by 6-12 months
Yairi and Ambrose 2005 book
Severity Rating Scale for Parents of Preschoolers
• Used in Lidcombe Program (Onslow, Costa & Rue, 1990)
• Parents mark an “x” in relevant box at end of each day to indicate severity of
stuttering for day
• Weekly charts are used by parents and clinical to assess child’s progress
• Evidence for its reliability and validity
*
*
*
*
*
*
*
Family History of Stuttering
• Stuttering has been shown to run in families (e.g., Reilly et al., 2009).
• Yairi and Ambrose (1992) found that 66.3% of preschool-age children
who stutter (CWS) had a positive family history for stuttering.
• Mansson (2000) found that 67% of persistent CWS had a familial
background of stuttering.
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Family History of Stuttering
• 198 preschool-age children who do (82 CWS; 67 boys, 15 girls) and do
not stutter (116 CWNS; 61 boys, 55 girls) and their parents enrolled in
the study
• 4 visits spaced out 8 months apart across 2 years
• Of the above 112 participants who completed three or more visits, 88
(78%) had caregivers who consistently reported a family history of
stuttering (whether present or absent) across the three visits. Thus,
the final sample included 88 children and their caregivers.
Tumanova, V., Choi, D., Clark, C., Conture, E. G., & Walden, T. A. (in preparation).
Family history, gender and stuttering chronicity.
Family History and Gender
There was a marginally greater likelihood
to have a positive family history of
stuttering for CWS than CWNS
There was no sig. gender ratio difference
between CWS with and CWS without a
family history of stuttering
Family History and Caregiver Concern
Higher TOCS-SFR scores were given by caregivers who
reported a FH of stuttering, regardless of whether
their children were diagnosed CWS or CWNS
TOCS-DRC scores were marginally lower
for parents of CWNS with a negative family
history compared to all other parents
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Family History and Recovery from Stuttering
• Recovery from stuttering was not
significantly different between CWS
with a positive versus CWS with a
negative family history of stuttering
• For children who stuttered at the
initial visit, neither gender (p=.522),
family history (p=.122), nor
interactions between gender and
family history (p=.484) significantly
predicted their recovery status at
the two year follow-up visit.
Caregiver concern for stuttering
• Data shows it is associated with frequency of stuttering
• What are the ways to assess it objectively?
Tumanova, V., Conture, E. G., Lambert, E. W., & Walden, T. A. (2014). Speech disfluencies of
preschool-age children who do and do not stutter. Journal of communication disorders, 49, 25-41.
Test of Childhood Stuttering
Gillam, Logan & Pearson, 2009
• Designed for children between the ages of 4 and 12 years
• Consists of three subparts
• Speech fluency measure made in several different linguistic contexts
•
•
•
•
Rapid picture naming (40 pictures)
Modelled sentences (produce a sentence using the clinician’s model)
Structured conversation (answer questions about a series of 8 pictures)
Narration (children tell a story based on the pictures used in structured conversation)
• Observational rating scales (can be filled out by clinician, teacher, caregiver)
• Supplemental clinical assessment used for a more detailed analysis of child’s stuttering
• Disfluency duration
• Speech rate
• Number of iterations per repetition
• Shown to have good validity and reliability
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Test of Childhood Stuttering
Observational rating scales
183 children and their parents
participated.
Parents of 90 children were concerned
about stuttering (CWS; 25 girls; 65 boys)
Average score of 15.34 on TOCS 1
Average score of 6.12 on TOCS 2
Parents of 93 children were NOT
concerned (CWNS; 43 girls; 50 boys).
Average score of 2.2 on TOCS 1
Average score of 2.2 on TOCS 2
Tumanova, V., Choi, D., Conture, E. G., & Walden, T. A. (in
preparation). TOCS, MLU and stuttering evaluation for preschoolage children
Findings
TOCS Speech Fluency
0
1
TOCS Disfluency Consequences
0
1
“Concerned” parents exhibited significantly higher scores on TOCS speech
fluency rating scale (p<.0001) and TOCS disfluency related consequences
scale (p<.0001) than parents of CWNS.
Children whose parents gave a higher score on TOCS speech fluency scale
stuttered more during evaluation.
Temperament
• Ambrose, Yairi, Loucks, et al. (2015) reported among other
differences (lower performance on standardized tests of language)
• CWS with persistent stuttering were judged by their parents to be
more negative in temperament
• Assessment Measures
• Children’s Behavior Questionnaire (CBQ; Rothbart, Ahadi, Hershey, &
Fisher, 2001)
• Behavior Style Questionnaire (BSQ, McDevitt & Carey, 1978)
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Assessment:
Child Assessment Components
Child Assessment Components
• Measures obtained from speech samples
•
•
•
•
•
Disfluency Count
Types of disfluencies
Duration of disfluencies
Speech rate
Mean length of utterance
• Standardized measures of speech and language
• Articulation
• Receptive and Expressive Language
• Children’s speech-associated attitudes and awareness
Healey, Scott Trautman, and Susca, (2004). Clinical applications of a multidimensional
approach for the assessment and treatment of stuttering. CICSD, 31, 40-48
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Parent-child interaction
• Done first to get unbiased sample
• Opportunity to observe child’s stuttering
and awareness of it
• Opportunity to observe parent’s style of
interacting with child
• Average speech rate for child and parent
• Video record for later analysis
Motor Component
• Frequency
• Type
• Duration
• Severity
• Secondary behaviors
• Overall Speech Motor Control
Speech Sample
• For assessment, attain two samples: one in clinic and one outside
• Outside samples
• Preschoolers: at home
• School-age: in school
• Adolescents and adults: at work or in a phone conversation
• Because stuttering is variable, ensure that sample is representative of
current level of stuttering
• Videotaping is important for major samples
• Samples must be long enough to get representative sampling of speech
• For major assessments, use 300-400 syllables for conversation and 200 for
reading
• For reading sample, ensure passage is at or below client’s level
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Assessing Frequency of Stuttering Behaviors
• Percentage syllables stuttered (%SS) (SSI-3 and 4)
• %SS = total stuttered disfluencies/total syllables
• Percentage of words stuttered (%SW)
• %SW = total stuttered disfluencies/total words
• When counting stutters, each syllable can only be stuttered
once (ex. N-n-n-n-n-nuh-nuh…[silent block]…name” = one
stutter)
• If client has obvious avoidance behavior without stutter,
may count as stutter (ex. “My name is
uh…uh…uh…uh…Ben”)
Yaruss, J. S. (2001). Converting between word and syllable counts in
children's conversational speech samples. Journal of Fluency
Disorders, 25(4), 305-316.
Assessing Types of Disfluencies
• Important in distinguishing normally disfluent children from those who
stutter
• Stuttered versus normal disfluencies
• Stuttered = part-word and single-syllable whole-word repetitions, tense pauses, and
dysrhythmic phonations
• Normal = multisyllabic word repetitions, phrase repetitions, interjections, and revisions
• If child has more than 3 stuttered disfluencies per 100 words, more likely to be
stuttering (=stuttering diagnostic criteria)
• If child has more than 10% of total disfluencies more likely to be stuttering
• If stuttered disfluencies comprise 50% or more of all child’s disfluencies, more
likely to be stuttering than normally disfluent
• Sometimes normal disfluencies can become stuttered (“uhm-uhm-uhm”)
Assessing Duration
• Common practice to average duration of three longest
stutters
• This is a component of severity assessment
• Use stopwatch to measure duration (to nearest one-half
second of longer stutters in sample). Average longest
three.
• The SSI-4
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Online vs. Offline
• Online diagnostic assessment = real-time analysis (Yaruss, 1998)
• Offline diagnostic assessment = transcript based assessment (i.e., SALT)
• Provide a measure of the frequency of various types of disfluency occurring
in a speech sample.
• Does not require a transcription.
• Provides information important to clinical decision-making.
• Transcribed analysis is time consuming and Real-Time Analysis can be done
more frequently, thus is a better tool for session-to-session documentation.
Online analysis: (Yaruss, 1998)
• Begin coding speech with a dash (-) for fluent words and an (x) or
coding symbol for a disfluent word.
• Coding Symbols used:
•
•
•
•
•
•
•
SSR = sound/syllable repetitions
WWR = single syllable whole word repetition
ASP = audible sound prolongations
ISP = inaudible sound prolongations
INT = interjection
REV = revision
PR = phrase repetitions
• Representative Sample. Do not worry about missing words or
maintaining pace with the speaker. Focus on obtaining a
representative sample.
• Intra-judge agreement is important.
Frequency:
% Total Words Disfluent (% TD) =
38/300*100 = 12.67%
% Total Words Stuttered (%SLD) =
36/300*100 = 12%
• % SLD/TD= 36/38*100 = 94.74%
• Sound prolongation Index = 14/36*100 =
38.89 %
•
•
Duration:
•
Average Duration of 3 longest SLDs =
(2.78+2.64+2.10)/3 = 2.51 seconds
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Assessing Secondary Behaviors
• Major division = escape versus avoidance behaviors
• Escape behaviors occur after stutter has started. They are an attempt
to stop stutter and produce a word (ex. Head nod, eye blink)
• Avoidance behaviors occur before stutter has begun. They are
attempts to keep from stuttering (ex. Saying extra sound, changing
word)
• Severity assessments often include measure of secondary behaviors
• Preschoolers who stutter close to onset have been reported to have
face and head movements (Yairi, Ambrose, & Niermann, 1993; Kelly &
Conture, 1991).
Assessing Severity
• Assessment of severity is a clinically relevant measure because it
captures what listeners experience
• Good for measuring progress in treatments that reduce
abnormality of stuttering but don’t eliminate stuttering
altogether
• Three instruments to assess severity
• Stuttering Severity Instrument-3 or 4
• Severity Rating Scale for parents of preschoolers
• Test of Childhood Stuttering
Severity Rating Scale for Parents of
Preschoolers
• Used in Lidcombe Program (Onslow, Costa & Rue, 1990)
• Parents mark an “x” in relevant box at end of each day to indicate severity of
stuttering for day
• Weekly charts are used by parents and clinical to assess child’s progress
• Evidence for its reliability and validity
*
*
*
*
*
*
*
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Assessing Speaking Rate
• Speaking rate vs. articulatory rate
• Only count syllables/words that convey information
• Severe stutterers may produce speech at a very slow
rate, decreasing their communicative effectiveness
• Individuals who both stutter and clutter may have
excessively fast rates of speech, making them somewhat
unintelligible
Linguistic Component
• Overall assessment of speaker’s language skills and
abilities
• Language formulation demands and their effect of
stuttering
• Stoker Probe
• Conversational speech sample
• Narrative speech sample
• Mean Length of Utterance
Children’s speech-associated attitudes and awareness
• Preschool Children
• KiddyCAT (Vanryckeghem & Brutten, 2002)
• Impact of Stuttering on Preschoolers and Parents
(Langevin, Packman, & Onslow.(2010). Journal of
Communication Disorders, 43, 407-423)
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Social Component
• Client’s communicative competence
• Reactions to various communicative situations
• Reactions to various communicative partners
• Any avoidances of speaking situations
• Any teasing as a result of stuttering
• Pragmatic aspect of communication
Tools to Assess Social Component
• Take information re: social component from questionnaires assessing
feelings and attitudes
• Observe client interact with different listeners/in different speaking
situations (home/school/clinic)
• During the assessment
• By asking parents/teachers for information
Cognitive Component
• Thoughts and Perceptions
• Negative view on their own stuttering
• Negative view on listener’s reactions
• Awareness and understanding of stuttering
•
•
•
•
Is client aware that he/she stutters
Can client identify moments of stuttering
Why do you stutter – client’s theory
How do you stutter – describe/show the SLP
• Theory of therapeutic change
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Treatment for preschoolers
Treatment options – none, waiting,
indirect, direct?
• Review risk factors specific to your preschool client
• Factors that may be associated with persistence of
stuttering:
•
•
•
•
•
•
Stuttering does not decrease during 12 months after onset
CWS is a male
Relatives who have not recovered from stuttering
Co-existing speech-language disorders
Below-average nonverbal intelligence scores
Sensitive temperament
Spontaneous Recovery Predictors
• Onset before age 3
• Female
• Measurable decrease in sound/syllable and word
repetitions, and sound prolongations, overtime,
observed relatively soon (6-12 mos) post-onset
• No coexisting phonological problems (and possibly
language and cognitive problems)
• No family history of stuttering or a family history of
recovery from stuttering
• ***All are probability indicators***
Yairi and Ambrose 2005 book
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Recommendations for Child with Typical
Disfluency
• Give information about normal disfluency
• If parents are concerned, set up another appointment in
several weeks to reevaluate if disfluency persists or
worsens
• If needed, recommend changes in environment that may
help all children: e.g., turn-taking, careful listening,
appropriate speech rates
Recommendations for Child with
Borderline/Beginning Stuttering
• Use risk factors and duration of stuttering since onset
and awareness of stuttering to determine if treatment
should be direct or indirect
• Teach parents to use severity rating (SR) scale and have
them begin to use it
• Borderline (usually younger preschool children):
•
•
•
•
•
Discuss with parents option of indirect treatment or watchful waiting
Provide online resources
e.g. Stuttering and the Preschool Child (Stuttering Foundation)
http://www.stutteringhelp.org/content/parents-pre-schoolers (E)
Have parents share weekly results of SR scale
Treatment Goals
• Speech behaviors targeted for therapy
• Aspects of family’s speech and nonspeech behaviors
• Fluency goals
• Spontaneous fluency
• Feelings and attitudes
• Work with family’s feelings, behaviors, and attitudes to keep
the child feeling positive about speech
• Maintenance Procedures
• Keep contact with family even after child has achieved
fluency; gradually taper off, remaining open to future contact
if needed
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Indirect treatment
• “Indirect” means that the child’s stuttering as well as their general
speaking abilities are NOT directly addressed.
• The focus is on adjusting the contexts in which communication occurs
to facilitate fluency.
• This type of therapy typically implemented first for children who are
likely to recover from stuttering
Indirect therapy
• Assess parental models during interactions with their children
• Turn taking; pausing, interrupting, eye contact, rate of speech, complexity of
child-directed speech/language, frequency of questioning
• Parents identify situations/behaviors by child and others that elicit
more stuttering
• Child’s own speaking patterns are analyzed to focus on stuttering
Indirect therapy
• Results of the assessment of parent-child interactions are then used
to identify behaviors to target in treatment
• Therapy typically involves sporadic sessions (initial 2-3 sessions, then
monthly visits, bimonthly, annual etc.)
• Often therapy is delivered in a group setting
• Parent group
• Children’s group
Parent reduces “time pressure” in daily routine, and “communicative
time pressure” in verbal interaction with child
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Treatment approaches that use this method
• Family-focused treatment
• Yaruss, J. S., Coleman, C., & Hammer, D. (2006). Treating preschool children who
stutter: Description and preliminary evaluation of a family-focused treatment
approach.Language, Speech, and Hearing Services in Schools, 37(2), 118-136.
• Demands and Capacities Model treatment
• Franken, M. C. J., Kielstra-Van der Schalk, C. J., & Boelens, H. (2005). Experimental
treatment of early stuttering: A preliminary study. Journal of Fluency
Disorders, 30(3), 189-199.
• Palin Parent-Child Interaction Therapy
• Millard, S. K., Nicholas, A., & Cook, F. M. (2008). Is parent–child interaction therapy
effective in reducing stuttering? Journal of Speech, Language, and Hearing
Research, 51(3), 636-650.
• Stuttering Prevention and Early Intervention treatment
• Gottwald, S. & Starkweather, C. (1995). Fluency intervention for preschoolers and
their families. Language, Speech and Hearing Services in Schools, 11, 117-126.
Working with Aspects of Parent-Child
Interaction
• Examples of typical family interaction patterns that may
stress a vulnerable child (E)
• High rates of speech
• Rapid-fire conversational pace (lack of pauses between
speakers)
• Interruptions
• Frequent open-ended questions
• Many critical or corrective comments
• Inadequate or inconsistent listening to what the child says
• Vocabulary far above the child’s level
• Advanced levels of syntax
Working with Aspects of Parent-Child
Interaction
• To help parents develop more fluency-facilitating interactions, clinician can model
for parent, and then have parent try new behaviors with clinician observing and
giving feedback (E)
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One-on-One Time with Child
• Parent should try to arrange 10-15 minutes per day of
one-on-one time with child to practice parent-child
interaction changes
• Best done at same time each day so child can look
forward to it
• Major characteristic is parent attending to child, good
listening, child-directed
Slower Speech Rate with Pauses
• Clinician teaches parents/family to use a slower speech rate
with appropriate pauses
• Videos of Mr. Rogers on YouTube can be helpful models for
clinician and parents
• Emmy Acceptance Speech 1997 (E)
• 143
• Parents/family benefit from practice with clinician to achieve
a relaxed and smooth slower speech style
• Then they can try it with child in clinic and at home; if child
asks why parent is speaking slowly, parent can tell child that
they talk too fast and need to learn to slow down
Measurements
• Severity Ratings
–
Use Lidcombe Severity Rating Scale which has 1-10 scale
–
1=typical fluency; 10=extremely severe stuttering
–
Parents use this scale to report daily severity of child’s stuttering
–
Clinician may use this also in clinic session
• Baseline Measures
–
Clinician records first 10-15 minutes of each clinic session and notes
child’s SR for session and compares with parent’s SR
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Severity Rating Scale for Parents of
Preschoolers
• Used in Lidcombe Program (Onslow, Costa & Rue, 1990)
• Parents mark an “x” in relevant box at end of each day to indicate severity of
stuttering for day
• Weekly charts are used by parents and clinical to assess child’s progress
• Evidence for its reliability and validity
*
*
*
*
*
*
*
Supporting Data
• Evidence that when mothers slow speech rate, child
becomes more fluent (Stephanson-Opsal & Bernstein
Ratner, 1988)
• Evidence that when parents change interactions, child
becomes fluent (Gottwald, 2010; Guitar et al., 1992)
Older Preschool Children: Beginning
Stuttering
• Child is between 3.5 and 6 years old and has been stuttering for at
least nine months
• Stuttering consists of repetitions, often with tension, as well as tense
prolongations, and some blocks
• Escape behaviors; may be some avoidances
• Feelings of frustration and embarrassment
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4/3/2016
Parent-Child Interaction Therapy (PCIT)
(Millard, Nicholas & Cook, 2008)
• Rooted in “multifactorial” model of stuttering
• Collaborative, flexible approach tailored to individual family
• Stuttering may be openly discussed and acknowledged with child
• Although this is primarily an indirect approach
• Tools based on
• child assessment,
• parent interview, and
• guided observation of videotaped parent-child play
to determine physiological, linguistic, environmental or
psychological factors
Parent-Child Interaction Therapy (PCIT)
• Basic goals
• Increase parent’s abilities to manage stuttering
• Reduce family anxiety about stuttering
• Decrease children’s stuttering to below 3%
Parent-Child Interaction Therapy (PCIT)
• Intermediate Goals
• To have parents identify and then change interaction patterns so that they
become fluency facilitative
• Increase parent’s confidence and decrease their level of concern re stuttering
(questionnaire responses, homework sheets, verbal responses)
• Gradually decrease child’s stuttering (stuttering frequency measures, parents
severity ratings)
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Parent-Child Interaction Therapy (PCIT)
• Major activities
•
•
•
•
Individual therapy sessions
Video recording and playback of parent-child interactions
Discussions between parents and clinician (E)
Homework for parents
• Special Time (5 minutes of play time 3-5 times a week for each
parent)
• Reflect on how special time is going, whether goals are achieved
Parent-Child Interaction Therapy
(PCIT)
Session 1
- Clinician feedback from evaluation and ‘discovery’ while
watching videotape.
- Management and Interaction tools are chosen.
- “Special Time” is negotiated.
Parent-Child Interaction Therapy (PCIT)
Interaction Tools During Play:
• Follow child’s lead during play and verbal interaction (less physically active role);
• Reduce instructions and questions (use comments instead);
• Maintain attention with eye contact, showing interest, encouragement and praise
• Reduce speech rate;
• Increase duration of turn-taking pauses;
• Reduce language demands (i.e. vocabulary, grammar, length/complexity of
utterances, amount of talking, “performance” requests)
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Parent-Child Interaction Therapy (PCIT)
Session 2
Videotape parent-child play and observe use
of selected interaction tools and their effectiveness;
Parent taught to observe relationship between
child “stressors” (internal and external) and fluency,
and modifies/manipulates when possible
Provide feedback sheets and schedule weekly parent
visits
Time commitment
• 1 hour per week for 6 weeks
• Then weekly 10-minute telephone contacts for 6 weeks
• Then 1 hour consolidation session
• Checkup every 3 months for 1 year
• Total contact time 8 hours
• Total duration of treatment 12 weeks + 1 year of monitoring
PCI Outcome Data
• Case studies
• Matthews, Williams, & Pring, 1997
• Crichton-Smith, 2002
• Millard, Nicholas, and Cook, 2008 (%SD reduction from 8.4% to 2.7% after a
year of treatment)
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Lidcombe Program
Onslow, Packman & Harrison, 2003
• Overview
•
•
•
•
•
•
•
http://sydney.edu.au/health-sciences/asrc/
http://sydney.edu.au/health-sciences/asrc/downloads/index.shtml
Parent delivered in-home operant program praise about every fifth utterance
Gentle correction for unambiguous stutters, only once per five praises
Parent guided by weekly clinic visits
Initially in structured sessions, then in unstructured sessions
Data guides changes in program
• Parent collects daily Severity Ratings (SRs)
• Clinician collects %SS (or SRs) at clinic visits
Lidcombe Program
• Basic goals
• Direct treatment for stuttering
• Behavior therapy for children younger than 6 years
• Decrease children’s stuttering to below 1%
• Major activities
• Individual therapy sessions
• Clinician trains parents to administer praise and corrections in structured and
unstructured daily situations
Clinical Procedures
• Stage 1: First Clinic Visit
• Clinician assesses child’s %SS or SR in 300 syllables of the
child’s conversational speech (standard for every clinic visit)
• Clinician teaches parents about using SRs on a 1-to-10 scale to
rate child’s fluency every day (E)
• To calibrate parent, clinician may ask parent to rate child’s
speech in previous 300 syllable sample; parent’s and clinician’s
ratings then compared and discussed
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Clinical Procedures
• Clinician teaches parent to conduct daily treatment
conversation at home for 10-15 minutes each morning
•
•
•
•
Conversation must be fun for child
Keep child’s response fluent by adjusting its length and complexity
Praise after every fifth fluent utterance: e.g., “That was really smooth!”
Praise must be specific to speech (“smooth talking!”) rather than general (“good!”)
Subsequent Clinic Visits
• Three goals
• Assess child’s speech
• Discuss SRs and other indicators of progress
• Introduce new procedures when appropriate
• After child’s speech is assessed, she plays by herself as
parent and clinician openly discuss child’s progress
Subsequent Clinic Visits
• Once parent is comfortable with using praise, gentle
corrections are introduced:
• After five praises for fluency, the next stuttered word is commented on,
acknowledging stutter: “That one was a little bumpy,” using a non-negative
inflection in the voice
• After parent is comfortable with using acknowledgments for a week,
requests for self-correction are taught
• “‘Truck’ was a little bumpy. Can you try that again?”
• If child says the word fluently, parent then praises: “Nice job of making that
word smooth!”
• Style of both praise and corrections can be adjusted to suit the child’s and
family’s preferences
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Stage 1: Introducing Unstructured
Treatment Conversations
• When structured conversations have been going well and the child’s
SRs and %SS show a reduction, unstructured conversations are
introduced
• This entails the use of praise, acknowledgment of stutters, and
request for correction in everyday situations such as when child and
parent are in the car or doing various activities around the house
• Unstructured treatment conversations can start with only praise and
contingencies for stutters introduced when appropriate
Stage 2: Maintenance
• Family begins Stage 2 when child meets criteria for three
weeks in a row
• %SS in clinic is below 1%SS
• Week’s SRs are all 1 or 2, with at least four days being 1
• Stage 2 consists of 30-minute clinic visits scheduled at
systematically increasing intervals as long as criteria are met:
• Two visits at two-week intervals
• Two visits at four-week intervals
• Two visits at eight-week intervals
• One visit at a 16-week interval
Stage 2: Maintenance
• If criteria are not met, parent and clinician jointly decide
among several possible options:
• Clinic visits increased in frequency to previous level
• Weekly clinic visits
• Reinstating either structured or unstructured clinic visits or
both
• Sometimes contingencies need to be adjusted
• Ex. When child rarely stutters, praise for fluency is sometimes
forgotten and parent only using requests for correction; praise
needs to be used whenever corrections are used
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Time commitment
• 1 hour per week for 6 weeks
• 15 minutes of daily treatment by parents at home during stage 1
• Intermittent daily treatment by parents at home during stage 2
• Median of 11 weekly sessions to achieve fluency
• 1 year of gradually faded contact
Outcome Data
• 42 children treated with Lidcombe showed near-zero
levels of stuttering four to seven years after treatment
(Lincoln & Onslow, 1997)
• 12-week randomized control trail of Lidcombe (n=10)
versus no treatment (n=13) showed that the treated
children had significantly less stuttering than untreated
(Jones et al., 2000)
• Randomized control trial of Lidcombe (n=29) versus
control (n=25) showed significantly greater
improvement in Lidcombe treatment (Jones et al., 2006)
What are the similarities between PCI and Lidcombe?
Onslow, M., & Millard, S. (2012). Palin Parent Child Interaction and the Lidcombe Program:
Clarifying some issues. Journal of fluency disorders, 37(1), 1-8.
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Direct Approach for Preschoolers
• Goals
•
•
•
•
Decrease time pressure and physical tension
Reduce speech rate (level I)
Contrast easy versus hard or smooth versus sticky speech (level II)
Prevent/modify stuttering by using stretchy (=prolonged) speech and/or soft
touches (=light articulatory contacts) (level III)
Reduce speech rate (level I)
• Turtle Speech
•
•
•
•
Contrast the concepts of fast and slow
One is more likely to lose control when doing something too quickly
Fast = out of control
Slow = in control
Contrast Smooth vs. Sticky speech (level II)
• Acknowledge that speech can be easy and smooth and can be hard,
sticky, or bumpy
• If child is not able to describe hard vs. easy speech, clinician can
demonstrate different kinds of speech herself
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Stretchy Speech (level III)
• Children may increase tension in their articulators or throat when
initiating speech sounds
• Teach them how to produce light articulatory contacts
• Soft touches
• Contrast hard vs. soft objects (marshmallows)
• Level of practice increases from sounds through sentences
Preschool-age children: Resources
• 7 Tips for Talking with the Child who Stutters
• http://www.stutteringhelp.org/videos
• Special Education Law & Children Who Stutter
• http://www.stutteringhelp.org/special-education-law-children-who-stutter
• Stuttering Home Page
• http://www.mnsu.edu/comdis/kuster/schools/SID4page2.html
45